Private healthcare providers and PHC:
gateway to marketization or untapped
potential to strengthen PHC?
Elisabeth Paul
Université de Liège (ARC Effi-Santé)
Université libre de Bruxelles (School of Public Health)
40 YEARS AFTER ALMA-ATA – PRIMARY HEALTH CARE
I N 2018 AND BEYOND, I N SOUTH AND NORTH
Facts
Private sector = important actor, in most countries
Mackintosh et al. (2016: 598)
Facts
Private sector = important actor, even for the poor
Mackintosh et al. (2016: 600)
Facts
Private sector = important actor, even for the poor
Mackintosh et al. (2016: 602)
Facts
Private sector = multiplicity of actors:
◦
For profit / not-for-profit
◦
Faith-based / ideology-based / other
◦
Modern / traditional
Private health sector 3 functions:
◦
Private healthcare providers
◦
Private health insurers
◦
Private “producers of resources” (training, leasing, pharmacies…)
Beyond institutional/administrative identity of healthcare provider: have a look at 5ealth
service purpose and nature of outputs (public = social, non-discriminatory,
population-based, goverment-policy guided, non-lucrative)
(Giusti et al. 1997)
High heterogeneity in qualification
(McPake & Hanson 2016)
Limited conceptualisation and difficulty in exploring the relations between factors, and
their effect on overall performance
(Roehrich et al. 2014, Morgan et al. 2016)
Limited and mixed empirical evidence on health PPPs – and esp. on efficiency and quality
of private sector PHC in LMICs
(Basu et al. 2012, Roehrich et al. 2014, Coarasa et al. 2017)
Opportunities
Increase coherence of health system
Expand coverage (population, specific services – e.g. SRHR)
Increase innovation and responsiveness to specific demands
Open the way to “third sector” actors’ values
Infrastructures and equipment: increased investment, economies of scale
Improve efficiency: ??
Wide variety of possible PPPs! adapt and frame to local contexts
◦
“Although some evidence shows that targeted supply-side interventions such as social
marketing and vouchers can increase coverage of focused services, less evidence is available
for accreditation and contracting, which seek to affect broad areas of service availability and
quality” (Montagu & Goodman 2016)
Role of private sector in progress towards UHC varies; interaction of many factors
affects how the sector performs in different contexts
(Morgan et al. 2016)
Conditions
Think systems!
◦
Complex interactions between private-public health sectors
(Mackintosh et al. 2016)
◦
“Changing the performance of the private sector will require interventions that target the sector as
a whole, rather than individual providers alone”
(Morgan et al. 2016)
Regulation (for all 3 functions) – but difficult
(inadequate in many LMICs? Montagu & Goodman
2016)
Quality controls – or support/encouragement to improve quality
(Montagu & Goodman 2016)
Ensure equity (private sector increased access often inequitable)
Financial protection of individuals
◦
“Where the private sector dominates the health system, the poor struggle to access fee-for-service
care, which is generally of low quality”
(Mackintosh et al. 2016)
Limit increases in total costs
Don’t improvise implementation! Set goals clearly, prepare well, and address challenges
(communication, HIS, etc.)
(e.g. Thomas et al. 2016)
Continue financing the public sector!
Limits
Back to basic economics: objective function of…
◦
Public sector: “multi-principal”, multi-objective problem: Max [coverage,
quality of care, equity, responsiveness, financial protection, broader
objectives of health system]; different ponderations according to societal
values (and political pressures)
◦
Private sector: Max π (profit)
PPPs are increasingly criticized in HICs
(Hall 2015, ECA 2018)
“The purchaser-provider split is typically justified in the name of
improved cost effectiveness, although the effects are usually the
opposite […] truly universal and equitable healthcare […] can best be
achieved by maintaining healthcare in public hands”
(Kumar & Birn 2018)
Role of the State very important in PPP/contractualisation
capacities?
Questions to be addressed by
the WG
1.
What are the most promising approaches enabling to
involve private healthcare providers for stronger PHC?
2.
What are the preconditions that need to be met prior to
involving the private sector more systematically?
Transversal thread: in what context?
Transversal threat: pragmatism and not ideology!
References
Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PLoS Med 2012; 9(6): e1001244.
Coarasa J, Das J, Gummerson E, Bitton A. A systematic tale of two differing reviews: evaluating the evidence on public and private sector quality of primary care in low and middle income countries. Globalization and Health 2017; 13:24.
European Court of Auditors (ECA). Public Private Partnerships in the EU: Widespread shortcomings and limited benefits. Special Report 2018/09. Giusti D, Criel B, de Béthune X. Viewpoint: Public versu private health care delivery: beyond the slogans, Health Policy and Planning 1997; 12(3): 193-198.
Hall D. Why Public-Private Partnerships don’t work. The many advantages of the public alternative. Public Services International (PSI) 2015. Kumar R, Birn A-E. Universal health coverage can best be achieved by public systems. BMJOpinion Blog, August 24, 2018.
https://blogs.bmj.com/bmj/2018/08/24/universal-health-coverage-public-systems/
Mackintosh M, Channon A, Karan A, Selvaraj S, Zhao H, Cavagnero E. What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries. Lancet 2016; 388: 596–60.
McPake B, Hanson K. Managing the public–private mix to achieve universal health coverage. Lancet 2016; 388.
Montagu D, Goodman C. Prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector? Lancet 2016; 388.
Morgan R, Ensor T, Waters W. Performance of private sector health care: implications for universal health coverage. Lancet 2016; 388. Roehrich JK, Lewis MA, George G. Are Public-Private Partnerships a Healthy Option? A Systematic Literature Review of “Constructive” Partnerships between Public and Private Actors. Social Science & Medicine; 2014.
Thomas C, Makinen M, Blanchet N, Krusell K (eds.) Engaging the Private Sector in Primary Health Care to Achieve Universal Health Coverage: Advice from Implementers, to Implementers. JLN for UHC Primary Health Care Technical Initiative; 2016.
